Kiwi, Arnim I --,- ? -- A-�9
NEW YORK CITY THE CITY OF NEW YORK—DEPARTMENT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
May 07,2020 12:01 PM 156-20-04196.4__
EVENT:(CHECK ONLY ONE) ®DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION ---------CERriFicnTe NUMBER
NAME First,Middle,Last AGE I SEX I DATE I MONTH DAY YEAR
Y)
Arnim Kiwi of
82 Male EVENT 05 05 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW YORK CITY
Queens Lon Island Jewish Forest Hills
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT CREMATION CREMATION APPROVED BY:
OF ME/MLI Adrienne Licking
Deslin Francois DISPOSAL ❑ OTHER M.E.CASE# Q20041350
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
R
DISPOSITION OF
Pine View Crematory Queensbury, NY DISPOSITION 05 08 2020
THE CERTIFICATE OF DEATH HAVING BEEN FILED AS REQUIRED BY THE HEALTH CODE,AND ALL LAWS AND REGULATIONS
GOVERNING THE PREPARATION AND DISPOSAL OF HUMAN REMAINS HAVING BEEN COMPLIED WITH, PERMISSION IS
HEREBY REQUESTED TO DISPOSE OF THE REMAINS AS IDENTIFIED ABOVE.
NAME OF ESTABLISHMENT ADDRESS CITY AND STATE N.Y.STATE REG.#
FUNERAL
ESTABLISHMENT Fox Funeral Home, Inc. 9807 Asean Ave Forest Hills NY 00603
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNAAT'URE ��p/y N.Y.STATE LIC.#
Steven Ducal O (.Iii.(.#/ Signature Electronically Authenticated 14007
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE QUESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department ��• ��;�r
of Health and Mental Hygiene;or if it has been corrected, :• A44:s "
interlined or altered in an manner.
y City Registrar
VR 21(REV.7/09) FEE PAID$ 40.00 DATE 05 / 05 /2020 %•�. •.•` By Service_E_vit_al
MM DD YYYY �'OFNE'S
1
Public Health Law Sec. 4145(2b)
i Receipt
t
Human remains of delivered on jrjn
Pine View Cemetery Representing the funeral home named
Official Funeral Directors Reg.or License#